Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Comorbid Conditions

Factors Influencing Duration

Length of disability depends upon the age of the individual, severity of the sprain or strain, whether the dominant or nondominant arm is affected, underlying medical conditions, complications, whether treatment is conservative or surgical, the individual's age, and the individual’s compliance with treatment and rehabilitation. If a grade III injury has occurred, there is an increased likelihood that permanent weakness may result in the inability to perform heavy or very heavy work.

Medical Codes

ICD-9-CM:

840.1 -

Sprains and Strains of Shoulder and Upper Arm, Coracoclavicular (Ligament)

840.2 -

Sprains and Strains of Shoulder and Upper Arm, Coracohumeral (Ligament)

Sprains and Strains of Shoulder and Upper Arm, Other Specified Sites of Shoulder and Upper Arm

Overview

The shoulder is one of the most mobile structures in the body; consequently its joint and associated soft tissues are highly vulnerable to injury. There are two main joints in the shoulder: the acromioclavicular joint, which connects the upper part of the shoulder blade (acromion) to the collar bone (clavicle); and the glenohumeral joint, which connects the socket of the shoulder blade (glenoid) to the upper end of the long bone of the arm (humerus). Ligaments (fibrous bands of tissue that connect the bones to bones) function to stabilize the joint. A shoulder sprain results in damage to the ligaments, usually from forces strong enough to stretch and / or tear the ligaments without causing a shoulder fracture or dislocation. The ligaments most frequently affected by a shoulder sprain include the acromioclavicular, coracoclavicular, and coracohumeral ligaments, each one named according to its origin at the scapula and insertion in the clavicle or humerus.

In addition to ligament damage, tendons (fibrous connective tissues that connect muscles to bones) also may be involved. A sprain is damage to tendons and the muscle(s) they are attached to. A shoulder strain may include damage to the muscles and / or tendons of the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis) as well as to the biceps or triceps muscles. When the proximal biceps tendon is severely strained, the cartilage of the shoulder socket (glenoid labrum) may become detached, resulting in a superior labrum anterior posterior (SLAP) lesion. On occasion, the muscles that attach the upper arm and shoulder to the chest (pectoral muscles), the back (latissimus dorsi, teres major), or those that stabilize the scapula (trapezius, rhomboids) may also become injured. Muscle strains most commonly occur in the dominant arm and are frequently the result of a forceful eccentric muscle contraction.

Ligament sprains are graded according to the severity of ligament damage and the resulting amount of joint separation: grade I or first-degree sprains involve stretching of the ligament fibers without joint separation. Grade II or second-degree sprains reflect stretching and tearing of some ligament fibers with minimal joint displacement, and grade III or third-degree sprains involve full thickness tears (rupture) of ligament fibers that result in joint dislocation (acromioclavicular dislocation, glenohumeral dislocation). More severe shoulder sprains are less common but may be graded from IV to VI, reflecting increased displacement of the bony anatomy (described in more detail in Dislocation, Acromioclavicular Joint).

Muscle and tendon strains are similarly graded according to the severity of muscle or tendon fiber damage. A grade I strain is a mild strain in which muscles or tendons become stretched, with few torn fibers and no loss of muscle strength. Grade II strains involve a greater number of injured muscle or tendon fibers with noticeable loss of strength. A grade III strain is a severe strain in which the muscle or tendon is ruptured, resulting in complete functional loss of the affected muscle or tendon. The grading of shoulder strains or sprains is not an exact science but is based on clinical assessment and experience related to signs, symptoms, or imaging studies.

Upper arm and shoulder sprains or strains typically occur as the result of direct trauma, falling onto an outstretched arm, overuse, or repeated attempts to lift or lower a heavy weight. However, with chronic degeneration of the muscle and tendon fibers, as occurs with impingement syndrome, older individuals may report a history of gradual onset of shoulder pain without known trauma. Sitting or working with poor posture also may predispose certain individuals to chronic muscle strain. SLAP lesions may be present in up to 20% of individuals with no known history of trauma (Snyder).

Incidence and Prevalence: It is estimated that 3.7 million individuals in the US visit their physicians each year for upper arm and shoulder sprains and strains ("Common Shoulder Injuries").

Acromioclavicular joint sprains are the most common athletic shoulder injury, accounting for 40% to 50% of the total cases requiring medical intervention (Seade).

Incidence of rotator cuff tears, especially of the supraspinatus tendon, increases with age; 32% to 37% of individuals over 40 years of age will have a partial thickness rotator cuff tear, although many are asymptomatic (Roy).

Studies of shoulder surgery report an underlying SLAP lesion discovered in conjunction with the primary shoulder disorder in 3.9% to 26% of cases, depending on the study (Kim; Tischer; Hasan).

Causation and Known Risk Factors

Risk of a sprain or strain of the upper arm and shoulder increases with participation in overhead reaching and throwing activities, repeatedly lifting heavy weights, direct trauma to the shoulder, falling onto an outstretched arm, participation in contact sports, and poor physical condition. Men are affected more frequently than women due to the increased likelihood of occupational physical labor and participation in contact sports.

Diagnosis

History: Individuals may describe sudden upper arm or shoulder pain following trauma such as a direct blow to the shoulder, a fall onto the outstretched arm, or a traction injury to the upper extremity. With a shoulder sprain, the individual may have felt a popping or snapping sensation at the time of injury with the sensation of an unstable joint, and may report nonspecific shoulder pain when reaching overhead or across the body. Popping, clicking, and catching sensations may occur with active movement, and the individual may complain of weakness and stiffness with arm use. Pain may also be noted at rest.

With an upper arm or shoulder strain, the individual may report pain with active movement and inability to use the affected muscle. If a full thickness tear has occurred, the individual may have observed a defect along the contour of the muscle. The individual may complain of inability to sleep on the affected shoulder at night, and pain may radiate down the side of the arm with activity.

Physical exam: Observation of the shoulder may reveal localized swelling (edema) of the soft tissues or within the joint (effusion), bruising (ecchymosis), a protruding distal clavicle (with grade III acromioclavicular sprain), or a defect or gap within the contour of a muscle (with grade III shoulder strain). Muscular atrophy from long standing disuse may be present when comparing the injured to the non-injured shoulder. With both sprains and strains, touching (palpation) of the shoulder structures may discern either nonspecific or localized tenderness.

The individual may demonstrate painful, limited active and passive range of motion of the upper arm and impaired strength when attempting to move the shoulder. With shoulder sprains, passive joint motion often reproduces painful symptoms and isometric resistance testing is normal. Looseness (laxity) of the joint may be present if the ligaments have been stretched. A crossover test (horizontal adduction) may elicit pain at the acromioclavicular joint in the case of a sprained acromioclavicular joint. With shoulder strains, active movement and muscle strength testing frequently reproduces pain and displays weakness or complete loss of muscle function. Clinical tests such as Speed’s test, in which the individual’s forearm is resisted while in a position of full elbow extension and supination may be performed to stress the biceps tendon and its labral attachment. Other diagnostic clinical tests may be performed to specifically identify the affected muscle or tendon.

In conjunction with orthopedic assessment, a neurological examination may be performed as the mechanism of injury that results in upper arm and shoulder sprains or strains may also damage nearby nerves (axillary, radial, and / or musculocutaneous nerves, as well as those involved in brachial plexus injury).

Tests: Plain film x-rays are generally not diagnostic for soft tissue injuries but may be performed to rule out fracture and to establish the position of the acromion, clavicle, and humerus. Osteoarthritis or calcific tendinitis may also be observed. Stress x-rays with the individual at rest and then holding a weight may demonstrate shoulder deformity (an elevated distal clavicle with respect to the acromion) and instability with severe acromioclavicular joint sprains. MRI can be very helpful for shoulder injuries that do not respond to nonoperative (conservative) treatment or to confirm a diagnosis before surgery. An arthrogram, in which dye is injected into the joint, is becoming much less favored because of its invasive nature, but may be helpful to highlight the area of injury. Ultrasonography can be used to help differentiate between a partial and full thickness muscle/tendon tear, but its success depends upon the skill of the ultrasonographer. With severe acute trauma, a CT scan may also be necessary. Electromyography is very helpful when there are complaints and physical findings of numbness and weakness in the absence of pain. On occasion, diagnostic arthroscopy may be used to examine the degree of shoulder damage if symptoms are persistent.

Treatment

In most cases, conservative treatment is recommended to resolve painful symptoms unless a rupture of the affected ligament, muscle, or tendon is present and results in significant shoulder instability or weakness.

Grade I and II shoulder sprains and strains are initially treated with rest, cold therapy, and nonsteroidal anti-inflammatory drugs (NSAIDs) to help reduce painful symptoms. A sling may be used for the first few days following injury to allow symptoms of acute pain to subside; however, prolonged use of a sling may lead to shoulder stiffness and slowed recovery time. Early range of motion exercises should be performed as tolerated to promote healing and reduce the risk of a frozen shoulder (adhesive capsulitis). Whereas grade I injuries will typically heal with conservative treatment, grade II injuries may also require physical therapy to improve range of motion and promote muscle strengthening.

Grade III shoulder sprains and strains may be initially treated with a sling and cold therapy, but many cases may require surgery to repair the ruptured ligament, muscle, or tendon. Acromioclavicular dislocations and grade III strains in older individuals are typically treated conservatively unless the individual engages in heavy overhead work or is very active. However, muscles and tendons that have sustained full thickness tears often require surgery to trim torn muscle or tendon fibers (débridement), to reattach the ruptured muscle or tendon, or to repair torn or detached cartilage (labral tear and SLAP lesion). Surgical repair of the shoulder muscles, tendons, or cartilage may be performed arthroscopically through tiny incisions using a fiberoptic scope and small instruments, or with open surgery to reconstruct larger, more complicated, or avulsed tears with grade III injury. A mini-incision between 4 cm to 6 cm long also may be used to access and repair torn soft tissues in certain individuals, promoting reduced healing time. Upper arm and shoulder surgery may be performed with either a regional or general anesthesia. Following surgery, rehabilitation is important to help the individual regain functional strength and mobility.

* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Prognosis

In general, individuals with shoulder sprain injuries demonstrate a good functional outcome with conservative treatment in the majority of cases. Successful outcome of conservative treatment for rotator cuff tears ranges between 33% and 90%, with older individuals requiring longer recovery time; younger individuals are more likely to have a good outcome than older individuals (Quintana). Re-rupture rates following rotator cuff tear can be as high as 50% according to MRI, but clinically the majority of these patients remain minimally symptomatic or asymptomatic (Gerber). Biceps tendon lesions, ranging from tendinitis to complete rupture, are commonly associated with rotator cuff tendon tears (grade III strains). Following biceps tendon rupture and surgical repair, outcome is good, although strength deficits may remain following recovery. If a SLAP lesion is also present, satisfactory outcomes generally require arthroscopic surgery to repair the torn cartilage.

Massive grade III strains and grade IV to VI shoulder sprains have a poorer prognosis and are associated with a higher degree of disability.

Rehabilitation

The goals of rehabilitation following an upper arm and shoulder sprain or strain are to decrease pain and restore full function with a painless mobile shoulder. The duration of treatment is related to healing response, the necessity of surgery, and any complications.

The focus of rehabilitation should emphasize restoring full range of motion and strength while maintaining independence in activities of daily living. While the resumption of pre-injury status is the goal, the grade of sprain or strain (grade I, II, III) will affect the speed of rehabilitation. Protocols for rehabilitation must consider the type of management (operative, nonoperative) and should be guided by the treating physician.

For the first 48 hours following injury, rest and cold therapy may be utilized to control painful symptoms and to reduce swelling. A sling may be used temporarily to immobilize the upper arm and shoulder. The next phase of rehabilitation should focus on shoulder range of motion and strengthening of involved structures. Modalities such as ice and heat may be used to control edema and facilitate participation in physical therapy. In some cases, pain control may also be achieved by using therapeutic ultrasound or iontophoresis (Stretanski), although ultrasound is contraindicated over an inflamed tendon as it may worsen the injury (Malanga). Individuals should be instructed in early flexibility exercises to restore passive then active movement to prevent the development of shoulder joint stiffness (adhesive capsulitis), which may severely affect recovery. Strengthening exercises are initiated, beginning with isometric exercises and scapulothoracic muscle strengthening then progressing to all affected muscles, including the rotator cuff, within pain free ranges of motion (Malanga). Individuals are instructed in proper postural mechanics with reaching activities, and in exercises to advance proprioception and activity-specific strengthening (Malanga). A home program should be taught to complement supervised rehabilitation and to be continued after the completion of physical therapy.

If surgery to repair torn ligaments, tendons, muscles, or cartilage has been performed, the individual’s upper arm and shoulder may be immobilized for several weeks to allow healing to occur. A biceps tendon repair may necessitate splinting of the elbow at 90° of flexion for the first 7 to 10 days dependent upon the surgeon’s protocol (Stretanski). Postoperative range of motion and strengthening exercises are progressed according to the recommendation of the treating surgeon. An ergonomic or workplace assessment may be indicated for certain individuals following a grade III sprain or strain to reduce risk factors that may re-injure the upper arm or shoulder.

Complications

Possible complications include re-injury, impingement syndrome, permanent loss of strength, residual pain, and any brachial plexus or vascular trauma sustained at the time of the shoulder injury. When a sprain or strain occurs, there may be bleeding into the tissues (hematoma) or into the joint space (hemarthrosis), which may need to be aspirated. Prolonged sling use may delay recovery, and lack of shoulder movement may lead to adhesive capsulitis.

Ability to Work (Return to Work Considerations)

Depending on work duties and whether the dominant or nondominant arm is affected, the individual may require accommodations to restrict lifting, carrying, pushing, pulling, and reaching activities. Individuals whose dominant arm is affected may require a temporary or permanent reassignment of job duties.

If surgery has been performed, resumption of activity should be based on the type of repair and the surgeon’s recommendation. During the recovery period, there may be prolonged restrictions on overhead work, lifting, reaching, and repetitive activities.

Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

Has individual sustained a traumatic injury to the upper arm and shoulder?

Did individual report a popping, tearing, or slipping sensation followed by a sharp pain in the shoulder?

When did sprain or strain occur?

On exam, is edema present? Effusion? Tenderness? Ecchymosis?

Is there an observable defect in the muscle? Muscular atrophy? Joint deformity?

Does individual have difficulty raising the arm above shoulder height?

Does individual report loss of muscle strength in the upper arm or shoulder?

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